Healthcare Provider Details

I. General information

NPI: 1669495859
Provider Name (Legal Business Name): DANIEL WONG DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 MILTON AVE
JANESVILLE WI
53545-0451
US

IV. Provider business mailing address

2525 MILTON AVE
JANESVILLE WI
53545-0451
US

V. Phone/Fax

Practice location:
  • Phone: 608-754-5340
  • Fax:
Mailing address:
  • Phone: 608-754-5340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberWI5001429
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: